| Goal 1 |
Improve the accuracy of resident identification. |
| 1A |
Use at least two resident identifiers when providing care, treatment or services. |
| 1B |
Prior to the start of any surgical or invasive procedure, conduct a final verification process, (such as a “time out,”) to confirm the correct resident, procedure and site using active—not passive—communication techniques. |
| Goal 2 |
Improve the effectiveness of communication among caregivers. |
| 2A |
For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. |
| 2B |
Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. |
| 2E |
Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions. |
| Goal 3 |
Improve the safety of using medications. |
| 3B |
Standardize and limit the number of drug concentrations used by the organization. |
| 3C |
Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. |
| Goal 7 |
Reduce the risk of health care-associated infections. |
| 7A |
Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. |
| 7B |
Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection. |
| Goal 8 |
Accurately and completely reconcile medications across the continuum of care. |
| 8A |
There is a process for comparing the resident’s current medications with those ordered for the resident while under the care of the organization. |
| 8B |
A complete list of the resident’s medications is communicated to the next provider of service when a resident is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the resident on discharge from the facility. |
| Goal 9 |
Reduce the risk of resident harm resulting from falls. |
| 9B |
Implement a fall reduction program including an evaluation of the effectiveness of the program. |
| Goal 10 |
Reduce the risk of influenza and pneumococcal disease in institutionalized older adults. |
| 10A |
Develop and implement a protocol for administration and documentation of the flu vaccine. |
| 10B |
Develop and implement a protocol for administration and documentation of the pneumococcus vaccine. |
| 10C |
Develop and implement a protocol to identify new cases of influenza and to manage an outbreak. |
| Goal 13 |
Encourage residents’ active involvement in their own care as a resident safety strategy. |
| 13A |
Define and communicate the means for residents and their families to report concerns about safety and encourage them to do so. |
| Goal 14 |
Prevent health care-associated pressure ulcers (decubitus ulcers). |
| 14A |
Assess and periodically reassess each resident’s risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks. |